Fillable Application - Colleges And Universities Supplement36-11161

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Application - Colleges And Universities Supplement36-11161

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COLLEGES AND UNIVERSITIES SUPPLEMENT
SUBMISSION REQUIREMENTS
• ACORD Application (for lines of coverage to be written)
• Drivers List with License #s and DOB
• Statement of Values
• Financial Statement
•
4 years of currently valued company loss runs
•
Schedule of Vehicles
GENERAL APPLICANT INFORMATION
Applicant:
Mailing Address:
Website Address:
Effective Date:
Risk Management Contact: Risk Management’s Phone:
Risk Management’s Email:
SECTION I – GENERAL INFORMATION
1. Total number of students enrolled:
2. Date school was founded:
3. Is this a private institution? Yes No
4. Does Applicant have a day care on premises? Yes No
If yes, what is the teacher to child ratio:
5. Does the Applicant offer medical training? Yes No
If yes, specify type:
6. Does the Applicant have any broadcasting operations? Yes No
7. Is there a foreign exchange program? Yes No
8. Does the Applicant sponsor any international travel? Yes No
9. Is there a Zero Tolerance Policy for hate crimes? Yes No
10. Are there any fraternities or sororities on the premises? Yes No
1. Is the Educational Institution accredited? Yes No
If yes, list accrediting organization(s): (check all that apply)
Middle States Commission on Higher Education
New England Association of Schools and Colleges Commission on Institutions of Higher
Education
North Central Association of Colleges and Schools The Higher Learning Commission
Northwest Commission on Colleges and Universities
Southern Association of Colleges and Schools Commission on Colleges
Western Association of Schools and Colleges Accrediting Commission for Community and
Junior Colleges
WASC Senior College and University Commission
New York State Board of Regents
Accrediting Council for Independent Colleges and Schools
Distance Education and Training Council Accrediting Commission
Association for Biblical Higher Education Commission on Accreditation
Association of Advanced Rabbinical and Talmudic Schools Accreditation Commission
The Association of Theological Schools in the United States and Canada Commission on
Accrediting
Transnational Association of Christian Colleges and Schools Accreditation Commission
Other:
School is: For Profit
Date school was chartered:
Not For Profit
• Educators Professional Select Application (for D&O/E&O,EPL)
SECTION II – ACCREDITATION INFORMATION
Colleges and Universities Supplement
Page 1 of 7
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07/2019
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Date of most recent review:
What was the outcome of the most recent review?
Accreditation Continued
Denial of Accreditation
Warning
Accreditation Continued –
follow-up report requested
Probation Withdrawal of Accreditation
Appeal
Show Cause
Other:
Are all programs offered at the schools accredited by the above listed association(s)?
Yes
No
Have any programs or degrees been accredited by additional specialist agencies?
Yes
No
If yes, please attach a listing of the program or degrees and the specialist agency.
Does the Educational Institution offer job placement services for students?
Yes
No
If yes, is there a disclaimer signed by students acknowledging that there is no job placement
guarantee?
Yes
No
What is the percentage of online courses?
%
Has the Educational Institution or any of the Educational Institution’s academic programs ever lost
accreditation, been placed on probation or become unable to gain accreditation?
Yes
No
8. In the last 12 months, has the Educational Instituting eliminated or closed any academic
programs, including music, arts or athletic programs?
Yes
No
In the next 12 months, does the Educational Institution anticipate eliminating or closing any
academic programs? Yes No
SECTION III- INFIRMARIES
Does Applicant have medical facility/infirmary?
Yes
No
Does the facility dispense medication?
Yes
No
Does the facility provide only immediate care/first aid?
Yes
No
Does the facility only serve students and employees?
Yes
No
Are there only over-the-counter drugs stored on premises?
Yes
No
Are written instructions from parents required prior to dispensing any medications to minors?
Yes
No
Is there any overnight care provided?
Yes
No
How many beds are in the infirmary:
Are there written operational procedures in place?
Yes
No
Is there a medical professional on staff?
Yes
No
If yes, please indicate which of the following and how many are employed by the insured:
Physical Therapist:
Psychologist:
Dentist:
RN:
Nurse Practitioner:
Physician:
Counselor:
11.
Does the medical professional carry their own malpractice insurance?
Yes
No
If yes, who is the carrier and what limit is carried:
12.
Are medical history and care records kept for each patient?
Yes
No
SECTION IV – ATHLETICS
1.
Does the Applicant obtain a signed release which includes a hold harmless agreement from the
parents/guardians of all participants and obtained annually?
Yes
No
2.
Are there procedures in place to verify that parents / guardians carry their own health insurance?
Yes
No
3.
Are medical exams required for all participants in extra-curricular sports?
Yes
No
4.
Is someone who is trained in first aid always present during practices and games?
Yes
No
5.
Is Student Accident Insurance carried?
Yes
No
If yes, what is the limit carried?
6.
Does the school have a written concussion management protocol that is compliant with current
state legislation?
Yes
No
a.
Does the Applicant distribute the written protocol to coaches, parents, and players, and
require the parent / guardian’s acknowledgement that they have received and reviewed?
Yes
No
b.
Does the protocol include training in recognizing the signs / symptoms of a concussion or
other closed head injury?
Yes
No
c.
Does the Applicant utilize base line testing?
Yes
No
d. Is the training required for all coaches and faculty involved in physical education or sports
instruction?
Yes
No
e.
Does the protocol when a concussion is suspected require:
i.
removing the athlete or student from play?
Yes
No
ii.
evaluation by an appropriated healthcare professional?
Yes
No
iii.
informing the athlete or students’ parents / guardians about the possibility of a
concussion and giving them information about concussions?
Yes
No
Colleges and Universities Supplement
Page 2 of 7
© 2019 Philadelphia Consolidated Holding Corp.
07/2019
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iv.
keeping the athlete or student out of play until an appropriate healthcare professional
certifies that the athlete or student is symptom free and gives the OK for them to return
to play?
Yes
No
f.
Does the Applicant utilize any concussion impact monitoring technology?
Yes
No
i.
If yes, name of manufacturer:
ii.
Who monitors the data:
Coaches
Employees
Volunteers
3
rd
Party
7.
Does the Applicant have any saddle animals or equestrian teams?
Yes
No
8.
Does the Applicant have any swimming pools on the premises?
Yes
No
If yes, are all swimming pools and spas compliant with Virginia Graeme Baker Pool and Spa
Safety Act?
Yes
No
If no, provide time table and action plan:
9.
Number of athletic trainers:
10.
Is the Applicant compliant with the Zackery Lystedt law? (only applicable in WA)
Yes
No
11.
Bleachers:
# of Outside:
Seating capacity:
How often inspected:
# of Inside:
Seating capacity:
How often inspected:
12.
Are any of the following offered? (check all that apply)
Archery
Equestrian
Snow Skiing
Bungee Jumping
Polo
Sky Diving
Climbing (Mountain, Rock or Wall)
Rugby
Trampoline
Crew/ Rowing
Scuba Diving
Water Skiing
Other:
Other:
Other:
SECTION V- DORMITORIES
1.
How many dormitories are owned by the Applicant?
2.
Is each room equipped with hard-wired smoke detectors?
Yes
No
3.
Are all visitors required to sign in and out?
Yes
No
4.
Are any of the following allowed in dorm rooms
Incense burners?
Yes
No
Hot plates?
Yes
No
Candles?
Yes
No
Toasters or Toaster ovens?
Yes
No
Space heaters?
Yes
No
Microwaves?
Yes
No
5.
Does the dorm have a no smoking policy?
Yes
No
6.
Are there emergency procedures in place including evacuation?
Yes
No
7.
Are there scheduled fire drills and regular testing of fire alarms?
Yes
No
8.
Is emergency lighting provided in the stairwells and hallways?
Yes
No
9.
Are staff members present in the dorm on all nights when occupied by students?
Yes
No
10.
Is there a scheduled security patrol for each building?
Yes
No
****Please complete a Statement of Values.
SECTION VI – SECURITY
1.
Are there security guards at the school daily?
Yes
No
2.
Indicate the number of personnel providing security services
Employed:
Unarmed security:
Armed security:
Contracted:
Unarmed security:
Armed security:
3. When security is contracted to a third party, is the contractor’s general liability / law enforcement
professional liability policy required to name the educational institution as an additional insured?
Yes
No
If yes, does the third party maintain a minimum limit of liability coverage and indemnify the
educational institution? Yes No
If yes, indicate the minimum limit of liability of general/policy professional liability coverage the
Applicant’s institution requires:
4.
Do security personnel have arresting authority?
Yes
No
5.
If there is employed armed security, are they trained or re-certified annually to the standards
required for public sector law enforcement personnel within the political subdivision for use of
weapons?
Yes
No
Colleges and Universities Supplement
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07/2019
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6.
Are criminal background checks and psychological reviews provided for all employed security?
Yes
No
If yes, how often are these checks and reviews conducted: Every months.
If no, explain:
7.
Is the Applicant’s security department accredited by the International Association of Campus Law
Enforcement Administrators (IACLEA)?
Yes
No
8.
Does a mutual aid agreement exist with local, city, or county police?
Yes
No
9. Does the Applicant permit staff, students, volunteers, or visitors to carry open or concealed
firearms on the premises?
Yes
No
10. If the Applicant does not permit open and / or concealed carry of firearms on any premises for
which the Applicant is requesting insurance coverage, do all locations have signage which
conspicuously identifies the building as a Gun Free Zone?
Yes
No
11.
Does security personnel store weapons on premises?
Yes
No
Does faculty, staff or employees store weapons on premises?
Yes
No
12.
Does the Applicant’s Weapons Ban Policy have any exceptions?
Yes
No
If yes, please provide a copy.
13.
Does the educational institution have emergency call boxes located throughout the campus that
are connected directly to campus security or policy?
Yes
No
14.
Does the educational institution provide after-hours security escort service for students?
Yes
No
SECTION VII – ABUSE & MOLESTATION
1. Does your employment process (for employees and volunteers) include verification of whether the
individual has ever been convicted of any crime, including sex-related or child abuse related
offenses, before an offer of employment is made? Yes No
2. Yes No
Yes No
Does the Applicant’s state permit you to do criminal background investigations?
If yes, does the Applicant routinely request and receive such background investigations?
Are Federal and State Criminal Background checks performed on
Staff? Yes No Volunteers? Yes No
3. Do any independent contractors have access to students or perform operations where they will be
physically touching another person? Yes No
4. If yes, please explain:
5. Does the Applicant perform background checks on hired independent contractors? Yes No
6. Yes No
Is there a new employee and volunteer orientation that includes training in abuse awareness?
7.
Does the Applicant verify employment related references? Yes No
8.
Does the Applicant conduct personal interviews? Yes No
9.
Yes No Does the Applicant have written procedures dealing with sexual abuse?
If yes, please attach a copy.
10.
Does the Applicant have a plan of supervision that monitors staff in day-to-day relationships with
students, both on and off premises such as class trips? Yes No
11.
Does the Applicant have a Sexual Abuse Awareness Program for students? Yes No
12.
Does the Applicant have a specific training for the faculty on identifying and reporting incidents of
sexual abuse and molestation? Yes No
13.
Has the Applicant’s organization ever had an incident which resulted in an allegation of
sexual abuse? If yes, please describe the incident:
Yes No
14.
Was a claim made against the organization? Yes No
15.
Was the case settled? Yes No
16.
Was the case taken to trial? Yes No
17.
How much money was paid in damages to the victim: $
18.
Does the Applicant’s current insurance program provide abuse and molestation coverage? Yes No
Claims madeIf yes, Occurrence If Claims Made - Retroactive Date:
Limits: $ Carrier:
Colleges and Universities Supplement
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07/2019
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SECTION VIII - AUTOMOBILE
1.
Does the Applicant use an independent school bus contractor to transport students?
Yes
a.
If yes, are Certificates of Insurance required from the contractor?
Yes
If yes, attach Certificate of Insurance.
b.
Is the school an additional insured on the contractor’s policy?
Yes
2.
Does the Applicant hire or borrow vehicles for non-busing purposes?
Yes
If yes, please describe purpose and length of time vehicles are hired or borrowed:
3.
Approximately how many cars are hired or borrowed annually?
Total cost of hire, bus contractors: $
Total cost of hire, other: $
4.
Are any buses leased or loaned to others or used by outside organizations?
Yes
If yes, please explain:
5.
Number of employees using their own vehicles for school business (occasional or full-time use):
6.
Yes
For those employees who use their own vehicles for school business, either full-time or
occasionally, does the school require the employee to carry primary insurance?
If yes, what is the minimum limit the Applicant is requiring them to carry? $
7.
Does the Applicant have a full-time fleet manager?
Yes
If yes, please advise:
Number of years in current position:
Total number of years’ experience:
If no, who is responsible for fleet safety and maintenance?
8.
Does the school have a routine maintenance program for all vehicles?
Yes
9.
Are maintenance records kept for each vehicle?
Yes
10.
Does the Applicant’s organization utilize GPS fleet telematics devices?
Yes
If yes, please check off the fleet telematics being utilized:
Plug In
Hard Wired
Mobile Phone
Other:
11.
What percentage of the Applicant’s fleet is provided with these fleet telematics devices? %
12.
Does the school obtain Motor Vehicle Reports on ALL employees?
Yes
If yes, when?
At time of hire
Annually
Randomly (based on accidents or suspicions)
13.
Does the Applicant have a formal driving policy in place with MVR standards?
Yes
a.
Is driving policy communicated in writing to all employees?
Yes
Does the policy prohibit the use of cellphones / electronic messaging while driving?
Yes
b.
Is a signed acknowledgement form kept on file?
Yes
If yes, please attach a copy of signed acknowledgement.
c.
Does the Applicant have written guidelines defining an acceptable Motor Vehicle Record?
Yes
If yes, attach copy of guidelines.
14.
What action is taken if an “unacceptable” driver is identifiable?
15.
Does the Applicant perform accident investigations for each automobile accident?
Yes
16.
Does the Applicant allow any newly hired drivers to operate vehicles without going through a
company-specific documented driver training?
Yes
17.
Describe any ongoing training provided to drivers:
18.
Describe security regarding bus / vehicle storage:
Locked Garage
Fenced Lot
Lighting
Security Cameras
Security Personnel
Vehicle Locked When Unattended
Other:
Colleges and Universities Supplement
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SECTION IX - WINTER WEATHER FREEZE-UP PROTECTION
1. Fire Protection and Testing
a. Is the building provided with an Automatic Fire Sprinkler System (AS)? Yes No N/A
i. If yes, approximately what percentage (%) of the building is sprinklered? %
ii. If yes, what type of sprinkler system is installed? Wet-Pipe Dry-Pipe Both
iii. If yes, when possible, is the sprinkler piping primarily run within conditioned
areas designed to ensure the temperature remains above the 45°F minimum
Yes No N/A
iv. If yes, is the testing & inspection by qualified sprinkler contractor completed
within past 12 months & includes a formal winterization revi
ew?
Yes
No
N/A
v. If yes, are the alarms tied to a 24 hour UL listed monitoring company?
Yes
No
N/A
2. Emergency Water Response (domestic and AS water lines)
a. Are water shutoff valves (domestic and AS water lines) marked and readily
accessible?
Yes
No
N/A
b. Are water shutoff valves exercised (closed and reopened) at least annually?
Yes
No
N/A
c. Is the staff qualified to respond and shut off the water main during normal business
hours and off hours?
Yes
No
N/A
3. Automatic Water Shutoff Devices
a. For domestic water lines, is there a water flow detection, notification and automatic
shutoff?
Yes
No
N/A
4. Unused/Vacant Spaces
a. Does Applicant have a formal process to turn off and drain domestic water lines for
these spaces?
Yes
No
N/A
5. Unheated Areas (attics, crawl spaces, exterior wall joists)
a. Are all domestic water lines located in areas heated to at least 45°F?
Yes
No
N/A
i. If no, please describe freeze prevention measures (e.g. temperature monitoring,
heat trace, full insulation):
This section must be completed by all risks that have a location in one of the following states: AR, CT, DC, DE,
GA, IL, IN, KY, ME, MD, MA, MI, MO, NH, NY, NJ, NC, OH, PA, RI, SC, TN, TX, VT, VA, WV, WI
temperature?
1. If no, please describe freeze prevention measures (
e.g. temperature
monitoring,
heat trace, full insulation on piping or roof):
6.
General Comments:
Colleges and Universities Supplement
Page 6 of 7
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07/2019
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FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief
and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true
and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information in this Application changes
prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the
quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
VIRGINIA APPLICANT: READ YOUR POLICY. THE POLICY OF INSURANCE FOR WHICH THIS APPLICATION IS BEING MADE, IF ISSUED,
MAY BE CANCELLED WITHOUT CAUSE AT THE OPTION OF THE INSURER AT ANY TIME IN THE FIRST 60 DAYS DURING WHICH IT IS IN
EFFECT AND AT ANY TIME THEREAFTER FOR REASONS STATED IN THE POLICY.
FRAUD NOTICE STATEMENTS
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR
INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION
CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THAT PERSON TO
CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY
BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS
($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN,
NM, OK, PA, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.
APPLICABLE IN COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN
INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE
IMPRISONMENT, FINES, DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO
KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE
OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM
INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY
AGENCIES.
APPLICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER
FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A
FELONY (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE
PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER
OR ANY AGENT THEREOF, ANY WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION
OR STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR
PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR
COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT
MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO.
APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS
FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT,
FINES OR A DENIAL OF INSURANCE BENEFITS.
APPLICABLE IN PENNSYLVANIA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
APPLICABLE IN NEW YORK: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME AND SHALL BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH
SUCH VIOLATION.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
_____
________________________________________________________
SIGNATURE DATE
SE
CTION TO BE COMPLETED BY THE PRODUCER/BROKER/AGENT
PRODUCER AGENCY
(If this is a Florida Risk, Producer means Florida Licensed Agent)
PRODUCER LICENSE NUMBER
(If this a Florida Risk, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
Colleges and Universities Supplement
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